PATIENT INFORMATION PERMANENT ADDRESS EMAIL: PHONE: Home Work Cell SEX M F AGE MARITAL STATUS M S D W SPOUSE NAME PATIENT SOCIAL SECURITY - - OCCUPATION EMPLOYER EMPLOYER ADDRESS EMERGENCY CONTACT NAME RELATIONSHIP EMERGENCY CONTACT PHONE NUMBER INSURANCE INFORMATION INSURANCE COMPANY #1 COMPANY NAME ADDRESS INSURED NAME ID# GROUP # PRIMARY INSURED: SELF SPOUSE SPOUSE SOCIAL SECURITY - - SPOUSE EMPLOYER SPOUSE DATE OF BIRTH INSURANCE COMPANY #2 COMPANY NAME ADDRESS INSURED NAME ID# GROUP #
1. I agree to pay $ 25.00 fine if I am unable to keep my appointment and unable to reschedule or notify the office 24 hours in advance. 2. If you have a deductible or copay, it is due at the time services are rendered. 3. Medicare patients: If you have secondary insurance, please give us your card at the time of your appointment; otherwise you will be required to pay 20% Medicare coinsurance at the conclusion of your visit. PATIENT SIGNATURE DATE RELEASE OF INFORMATION I authorize the release of all information necessary to process my insurance claims and pertinent to my medical care. This release will remain in effect until revoked by me in writing. A photocopy of this release is to be considered as valid as the original. PATIENT SIGNATURE DATE
Assignment of Benefit The undersigned hereby authorizes the release of any information relating to all claims or benefits submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits for services rendered or for services to be rendered without obtaining my signature on each and every claim to be submitted for myself and/or dependents, and that I will be bound by this signature as though the undersigned had personally signed the particular claim. I hereby authorize insurance to pay and hereby assign directly to DIABETES & THYROID ENDOCRINOLOGY CENTER PC all benefits, if any, otherwise payable to me for his services as described on the claim forms. I understand I am financially responsible for all charges incurred. I further acknowledge that any insurance benefits, when received by me and paid to DIABETES & THYROID ENDOCRINOLOGY CENTER PC will be credited to my account, in accordance with the above said assignment. I hereby agree and understand that if I receive payment from my insurance company for services rendered by DIABETES & THYROID ENDOCRINOLOGY CENTER PCI am to endorse the check and mail with statement to her office. I clearly understand that it is still my responsibility to make sure the bill is paid in a reasonable time. If for any reason any portion of my bill is not paid by my insurance, I further agree to make arrangements for prompt payment of the bill. PATIENT'S SIGNATURE DATE / /
MEDICARE PATIENTS Patient s Medicare Number: I request that payment of authorized Medicare benefits be made on my behalf to Diabetes and Thyroid Endocrinology Center, PC or any of the individual physician members for any services furnished to me by any of its individual providers. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Service and its agents any information needed to determine these benefits or the benefits payable for related services. MEDICARE PATIENT SIGNATURE DATE
REQUEST FOR CONFIDENTIAL COMMUNICATIONS I request that all communications to me (by telephone, mail or otherwise) by Diabetes and Thyroid Endocrinology Center, PC and/or its staff be handled in the following manner: 1. For written communications: Address to 2. For oral communications: Call (Phone number): May we leave a message? Yes No 3. May we discuss your medical condition with members of your family or others you identify? Yes/No Name Phone Relationship PATIENT SIGNATURE DATE ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Patient Name: DOB: / / I have been presented with a copy of Notice of Privacy Practices, detailing how my information may be used and disclosed as permitted under federal and state law. I understand and agree with the contents of the Notice. I also hereby consent to the disclosure of my health information for the following purposes: (1) to provide my health care treatment; (2) to obtain payment for the services provided to me; and (3) to carry out ordinary health care and business operations. Patient or Legal Representative Signature Date
REASON FOR VISIT PATIENT MEDICAL HISTORY ALLERGIES: DO YOU SMOKE? PACKS PER DAY DO YOU DRINK? HOW OFTEN PAST MEDICAL HISTORY: (Please list your significant illnesses and when they were diagnosed) PREVIOUS SURGERY: (Please provide approximate date) FAMILY HISTORY: (Please list any significant illnesses of your grandparents, parents, siblings and children)
MEDICATIONS: (Please all medications including non prescription and over the counter items such as vitamins, that you take on a regular basis. Include the name, dose and frequency with which you take it.) 6. 7. 8. 9. 10. 1 1 1 1 1 Please provide us with the name address and phone number of the pharmacy you generally use: Please provide the name and ID for mail-away pharmacy, if you have one: TREATING PHYSICIANS: (Please list all your current physicians and phone numbers) Primary care physician Ophthalmologist (Eye) Nephrologist (Kidney) Podiatrist (Feet) Other